Learning to be Lean: One hospital's staff discovers improving efficiency isn't easy

Editor's note: This version of the story was edited to appear in the print edition of Modern Healthcare. View the full feature and video at modernhealthcare.com/learning-to-be-lean.

On a Wednesday morning early last month, a dozen nurses, housekeepers, surgical technicians and surgical assistants at Presence Health's Sts. Mary and Elizabeth Medical Center are running behind in their hunt for ways to save time on the hospital's busy surgical floor.

While other staffers performed their usual duties, the group, meeting in a conference room with a wall full of brightly colored Post-it notes, is midway through the challenge handed them by the hospital's leaders. They are spending a full week observing their colleagues' actions between surgeries to identify inefficiencies and devise a streamlined workflow.

On this third day, Maria Vela, peering at the wall with one hand on her hip and the other on her chin, suggests surgical technicians like her be given the task of carting new patients into the operating room. Nurses, who usually perform this task, are too busy entering patient information into the electronic health-record system and grabbing supplies to restock the rooms, she says.

“They would refuse, even in an experiment,” immediately counters Jackie Kostakes, the nurse on the team. Nurses need to verify patients' identities, a key part of maintaining patient safety, she argues.

At the beginning of the week, the people in the room barely knew each other. Some had never talked about their tasks. Now they are trying to figure out how to reduce operating room turnaround times on the eight-suite surgery floor—from an average of 30.55 minutes to 25 minutes.

Paresh Parikh, a surgical assistant, throws more cold water on Vela's suggestion. The surgeon needs to talk with the patients first to ensure the correct body part is marked for the surgery, he says. “It wouldn't work.”

The tension in the room mounts. The team needs to generate a final list of solutions by the end of the day. Every proposal seems flawed.

The tactic being used at Presence—where front-line workers spend a week experimenting with ways to improve a production process—is known as a breakthrough rapid improvement event. It's part of the Lean quality improvement method now in use at a number of hospital systems across the U.S.

Sandra Bruce, CEO of Presence Health, launched the 12-hospital system's Lean initiative in 2012 to boost employee engagement and slash inefficiencies that hindered the delivery of high-value care. The OR turnaround time initiative is this particular hospital's seventh rapid improvement event aimed at perioperative services. Previous events covered inpatient preparedness for surgery and completing checklists before patients reach the holding area.

Over the course of the rapid improvement week, which was observed by a Modern Healthcare reporter, the discussions among team members become more candid. Complaints are aired about less productive staffers, older workers supposedly being less proficient working with EHRs, and management not spelling out clear job roles.

Each problem is written on a Post-it note and stuck to the wall of the war room, where team members gather between each day's work-site inspections. “We're going to need a lot more Post-its,” jokes Marj Welchans, as she searches for an empty spot on a wall. Welchans, who works as a facilitator at Presence Health's United Samaritans Medical Center in Danville, Ill., is what the Lean team calls the “outside eyes”—a staffer from another department.

The impasse between Vela and her co-workers is not uncommon during Lean process improvement work. Over the course of the week, team members try some things that work and others that don't. They keep tinkering, hoping to muddle their way to a more efficient way to handle patients, provide treatment and manage supplies. While they will have an opportunity to revisit and refine those processes in the following months, the streamlined processes are slated to begin the following Monday.

Throughout the week, Lean team facilitator Ronald Guidizi, a former nurse who now works as one of 35 “breakthrough improvement” facilitators employed at Presence hospitals, stresses that it's all up to the team members. “We design the new world,” he tells them in a message that's both encouraging and intimidating.

Baylor Scott & White Health, Denver Health, Virginia Mason Medical Center, ThedaCare, Group Health Cooperative, Seattle Children's Hospital, Massachusetts General Hospital and Emory Healthcare are among the health systems that have adopted Lean methods to redesign clinical and business processes. The improvements developed by Lean teams generally aim to create standardized protocols, cut waste and develop cultures of continuous improvement that allow hospitals to adapt to rapid changes in the healthcare system.

But despite proven results, a limited number of health systems are using the Lean method. It requires the commitment of time and resources. It also can be difficult to get some hospital and physician leaders to embrace the Lean approach, which relies on engaging lower-status front-line staff in problem solving.

“The way they have done business for their entire career is turned completely upside down,” says Dr. John Toussaint, who introduced Lean principles when he served as CEO of Appleton, Wis.-based ThedaCare from 2000 to 2008. He later launched the ThedaCare Center for Healthcare Value, which educates healthcare executives on Lean implementation and whose annual conference in June drew representatives from more than 300 organizations.

Martin Judd, CEO of Sts. Mary and Elizabeth Medical Center, acknowledges he was skeptical when he and other Presence leaders were asked to participate in a two-day Lean breakthrough event last fall. “I drove the team crazy,” he recalls. “I did not want to be there.”

But after seeing the outcomes of breakthrough events at other hospitals in the Presence system, he is now an enthusiastic supporter. “I was floored by what they came up with,” he says. “It really demonstrated to me the power of giving the teams the gift of time to make the work better.”

Bruce, who steps down as Presence Health's CEO on Oct. 1, says frontline staffers know how to solve problems, but too often are never asked. “The engagement level and morale of employees is higher when we bring them into the performance improvement work, let them describe the problems, seek out the data and come up with solutions,” Bruce says.

The Lean methodology was developed by Toyota Motor Corp. as part of the automaker's vaunted Toyota Production System. Like other total quality improvement methodologies such as Six Sigma, Lean was picked up by U.S. manufacturers more than three decades ago. Only in the past decade has it found its way into the healthcare system.

The beauty of Lean is that it engages the creativity and skill of the front-line staff doing the day-to-day work, says Mark Graban, a Dallas-based consultant and author of several books on Lean. “It's much more effective than someone saying, 'I'm going to come fix it for you.'”

Some health systems using Lean hire outside consultants. Others, like Presence Health, have hired their own Lean facilitators. Some are just “dabbling here and there,” while others have committed to transforming their organizations through systemwide Lean process improvements, Graban says.

Application of Lean in healthcare continues to evolve. Rather than routinely pulling staff away for weeklong rapid improvement events, Dallas-based Baylor Scott & White Health now limits such events to major initiatives. Instead, everyone from top leaders to cleaning staff participates in daily huddles to identify and implement improvements. “Every single day, every person has the ability to bring forward an idea that can close the gap, without having to participate in a big event,” says Steve Hoeft, Baylor Scott & White Health's senior vice president of operations excellence.

Kathleen Long, Presence Health's director of breakthrough improvement, says one of the biggest challenges to overcome in Lean implementation is the commitment of staff time. “Health systems are so incredibly broken, but nobody takes the time to step back and say, 'Does the way we do this make sense?' ” she says.

At Presence Health, top executives attend two-day leadership events to decide which specific operational areas—called “value streams”—such as revenue cycle, emergency department and supply chain offer opportunities to boost efficiency and save money. The hospital leaders pinpoint specific areas where time or resources are being wasted, and plan monthly rapid improvement events in which front-line staff tackle manageable chunks of problems.

At Presence, each event involves a nine-step, problem-solving process that includes analyzing the workflow, crafting new goals and processes, identifying gaps that inhibited them from reaching the goal, and devising experiments to test the changes.

The problem the surgery unit team was asked to address in August was the excessive time for cleaning, disinfecting and restocking the ORs after an operation. The slow turnovers delayed procedures, frustrated patients, physicians and staff, and reduced the volume of procedures that could be performed, thus cutting hospital revenue. “Freeing up 6.5 minutes per case has the potential to add $600,000 of added revenue over the course of a year,” Long says.

But freeing up those minutes is proving to be a tougher task than many on the Lean team anticipated.

After learning about Lean thinking on Monday, on day two the team members shadow colleagues doing their normal work, identify waste and start brainstorming solutions. The team hits the surgery department floor armed with floor maps, stopwatches and notepads. When hernia, joint replacement and cyst-removal operations are completed, team members run to keep up with staffers moving from the OR to supply storage closets, to the patient holding area, and to other locations. They time how long it takes.

Some staffers stop to offer insights. Others seem irked by the observers. “Holy cow! It was dizzying,” Andrea Ramel exclaims at the end of the second day. She is training to be a breakthrough improvement coordinator.

Surgical tech Vela notes the tremendous variation in the room-turnover process. Team members find that completed patients are sometimes carted to the recovery room by a nurse and sometimes by a surgical assistant. EHR information sometimes is charted before patients leave the OR and sometimes after. “We need a repeatable process,” Vela says.

If the next surgery involves a medical device, the manufacturer's representative has to be found and brought to the room. But Emily Manning, an administrative intern who participates on the Lean team, observes that it's hard for nurses to coordinate the arrival of the new patient and simultaneously track down the manufacturer's representative.

There also are problems with storage of surgical supplies, which sometimes have to be retrieved from another floor or are missing entirely. Nurse Kostakes says some staffers voluntarily come to work an hour early just to pull these supplies together ahead of time.

That type of heroic effort, where highly motivated staffers develop workarounds in a broken system, is a classic red flag, says Lean expert Graban.

But the Lean team's most surprising observation is that when surgical floor staffers are followed by the team, they consistently perform room turnover in 18.4 minutes, more than five minutes faster than the target goal of 25 minutes. The finding suggests that the turnover time goal could be met if staff members are simply held accountable.

On the third day, the group is scheduled to test, adjust and retest potential solutions to see whether they make an impact. Late that Wednesday, the team members post ideas on how to change the workflow.

Kostakes says work schedules could be changed so that supply stockers come in earlier to make supplies easily accessible. Iris Meneses, the housekeeping supervisor, suggests storing supplies in a single place, cutting down walking time. Surgical assistant Paresh says the charge nurse should immediately tell the room turnover staff when a surgical procedure is complete so they can get started faster.

Then Vela makes her suggestion that patients be wheeled into the OR by technicians. The nurse and surgical assistant push back. As the tension mounts, Barb Cwiak, the surgery manager, wanders in for a progress update.

“We don't want to offer solutions we know people won't do,” Kostakes says with a sigh. The others nod. “What are the chances they'll cooperate?”

Cwiak steps in. “You're always going to get pushback, no matter what,” she says. “But whatever this team comes up with, we'll do.” Ultimately, the Lean team decides to assign some of the nurses' responsibilities, such as looking for supplies, to surgical assistants and technicians to free up the nurses.

The Lean team then prioritizes the recommended changes in terms of difficulty and level of impact. Changes that are too difficult or that will have minimal impact are removed from the action list. “You try to get improvements down to manageable chunks,” Long says.

Some issues end up in the “parking lot,” a term for difficult issues that only hospital administrators can address.

On Thursday, the team returns to the surgical floor to let everyone know the new way of doing the work. They quickly grab staff members and hand them laminated sheets detailing their new assignments.

A nurse poses so many “but what if” questions that Kostakes spends more than 10 minutes firing back “then we will” for each scenario. “I hope people follow the protocol,” the nurse says before she rushes down the hall to check on a patient.

On Friday morning, more than 50 people, including hospital CEO Judd, chief nurse Suzanne Lambert and surgery director Kevin Hoak, fill a large conference room to hear the team's final report. Some front-line staffers and leaders who participated in previous Lean events attend out of curiosity.

The Lean team members confidently present their proposed changes, which include rewritten job descriptions. They recommend assigning Lean team members to help each shift implement the new work processes. Starting Monday, there will be a daily huddle to discuss cases that do not meet the new 25-minute room turnover standard.

Lean boosters say support from top management is crucial to success of the program. Front-line staffers who perform rapid improvement experiments “love to have me come in on Fridays when we have the report-outs to hear not only their great work, but to ask for my help in the solutions,” says Presence Health CEO Bruce.

But the weeklong event is only the first step in the process. Data will be collected. Reports will be issued monthly for the next three months. Further changes will be made. Success is not guaranteed.

Long says previous Lean efforts at Presence Health hospitals have produced lasting improvements. Perhaps more significantly, they have created a culture where employees feel empowered to send issues of concern up the ladder to leadership.

The Lean rapid improvement process is exhausting and time-consuming. But supporters say it's one of the best ways to increase efficiency, reduce costs, and enhance patient and staff satisfaction. “Show me something else that works, and I'll try that,” Long tells skeptics. “We can't just keep doing the same things and hope somehow a miracle is going to come from the sky.”